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Physiological jaundice

Usually caused by increased red call mass caused by shortened lifespan of fetal Hgb. Decreased gut motility. Decreased gut flora. Leads to decreased excretion. Hangs around and is reabsorbed. Increased hepatic circulation of bile. Causes increased bili. Book lists causes as: (1) Increased red cell mass in the neonate combined with shortened life span of fetal hemoglobin leads to greater daily production of bilirubin than is seen in the adult. (2) Decreased activity of UDP glucuronyl transferase (UDPGT) that correlates with gestational age, leading to decreased conjugation and excretion of bilirubin. (3) Increased enterohepatic circulation due to lack of intestinal flora, decreased gut motility, and small enteral intake, all of which are seen in the first days of life.
o Bili levels rise around day 3. Decline by day 10-12. Don’t rise much above 5-7 mg/dL.
o Breastfeeding doesn’t need to be stopped. Increase feeds. May supplement with formula to help bili levels decrease (casein hydrolysate formula). This formula helps in a more rapid decline of serum bili. It inhibits the glucuronidase.


Pathological jaundice

Greater than 0.5 mg/dL/hr increase in bili levels. Appearance of jaundice earlier (in 1st 24 hours). Usually over 12 for bili level. Jaundice lasts longer. So, earlier, faster, higher, longer.


Causes of pathological:

Antibody-mediated hemolysis causes: ABO incompatibility, Rh incompatibility. Positive Coombs test indicates antibodies in serum. Antibodies on red blood cells. These can attack the system and cause erythroblastosis in the baby.
 Non-antibody hemolysis causes: Changes in shapes of red blood cells such as red cell membrane defects (hereditary spherocytosis, elliptocytosis), red cell enzyme defects (G6PD deficiency, pyruvate kinase deficiency).
 Non-hemolysis causes: Bruising, internal hemorrhage, polycythemia.


Indirect (unconjugated) is

bili in the bloodstream (reversibly bound to albumin).


Direct (conjugated) is

bili conjugated with glucuronide. It is water-soluble.


Breastfeeding jaundice

Physiological or pathological. If it persists (more than 3-4 weeks after birth) it is uncommon and is more likely to be pathological. Babies are feeding well and still persists: more serious pathological jaundice.


Signs of bili toxicity

Lethargy, hypotonia, fever, seizures, encephalopathy, poor suck, irritability, high pitched cry, backward arching of neck (retrocollis), opisthotonos (arching of trunk), kernicterus (25-30). Encephalopathy is a sudden toxicity that occurs during the first weeks of life. Kernicterus is chronic and permanent clinical sequelae of bili toxicity (cerebral palsy, auditory dysfunction, dental enamel dysplasia, paralysis of upward gaze, intellectual handicaps).


Risk factors for severe jaundice:

Family history risk factors include: significant hemolytic disease, anemia, inborn errors of metabolism, early/severe jaundice, ethnic or geographic origin associated with hemolytic anemia, hepatobiliary disease, previous sibling who received phototherapy, predischarge TSB or TCB in the high-risk zone. A personal history of these: ABO or Rh incompatibilities in previous pregnancies, sepsis risk for the infant (such as prolonged ROM), macrosomic infant of diabetic mother, cephalohematoma, significant bruising, exclusive BF that is not going well, East Asian race. Risk factors for pathologic jaundice include: appearance of jaundice in first 24 hours of life, rise of bilirubin greater than 0.5 mg/dL/hr, or conjugated bili greater than 2 mg/dL. Early or severe jaundice is esp concerning (first 24-36 hours of life). Early gestational age (35 weeks or earlier). Book states <38 weeks. Maternal age >25 yo. Male sex.


Decreased risk factors of jaundice include

African American, discharged from hospital after 72 hours of life, gestational age at 41 weeks or greater, exclusive breastfeeding that is going well or exclusive bottle feeding (asynch states bottle feeding), TSB or TCB in the low-risk zone.


Nonphysiological/pathological jaundice is

more severe.and requires more in-depth workup and look for risk factors. Most severe is early and severe jaundice. Greater than 0.5 mg/dL/hr rise of bili. Appearance in 1st 24 hours.


Treatment of jaundice

Continue to BF. Add casein hydrolysate formula. Phototherapy. Bilitool.org helps assess risk, interpret levels, and when to start treatment. Tool determines level based on age in hours and bili levels. Total serum bilirubin + hours of life. Tells if in high, intermediate, or low risk zones.


Key points about jaundice

Remember jaundice is observed most often during the 1st week of life in approximately 60% of all term infants. If bili levels rise early and persist long-term, it can be pathological instead of normal, physiological. Why breastfeeding causes jaundice? Starvation. Mechanism: Decreased enteral intake with increased enterohepatic circulation, analogous to starvation jaundice in adults. Note that jaundice may be an important indicator of inadequate breast milk supply or inadequate nursing and should prompt specific inquiries into this possibility.


Rule of thumbs for jaundice

Monitor all infants for jaundice. Use standard protocols. Interpret all levels by infant’s age in hours.


Newborn Weight

The infant may initially lose up to 5-8% of birthweight but should regain it within 10-14 days. Weight loss of 10% or more requires close monitoring and may require further evaluation. Weight gain after the initial loss averages 0.5-1 ounce/day or about 2 pounds/month.


When do you routinely encourage healthy newborns to see primary care provider after discharge?

48-72 hours after hospital discharge (around 3-5 days of age).


How to know baby gets enough breastmilk?

Baby should gain 0.5-1 ounce/day. Regain birthweight by 2 weeks of age. Weight checks. Wet diapers = 8 in 24 hours. Minimum 8 feedings in 24 hours. Double birth weight by 6 months. Triple by 12 months. Look at number of wet diapers and feedings.


To monitor growth: CDC says to use

WHO growth standards for breastfed babies up to 24 months


If baby seems to feed all the time and mom is exhausted

growth spurts. Add reassurance and tell moms growth spurts are common. Can last 3-4 days. Might be as little as 3-4 weeks apart. Increase feedings. Rest when she can. Pump if she has to. Doesn’t mean baby isn’t getting enough. Just means demand has increased. Don’t add formula.


Signs of poor weight gain

Unresponsive, sleepy, lethargic. Concerned if sleeping more than 4 hours between feedings. Can be a sign of poor weight gain. Poor skin turgor, dry mucus membranes. Watch to make sure babies are latching properly, hold is correct, hunger cues are picked up. Watch for poor weight gain when assessing babies.


Breastfeeding information

Watch for latch, support groups, appropriate weight gain, stress reduction, PNVs, vitamin D (for mom and baby). Vitamins D & K is not found in breastmilk. Vitamin K is absent (delay administration until after first feeding, but within 6 hours of birth). Vitamin D is not bioavailable. 200 IUs/day for all infants the 1st 2 months of life. Thureen and Asynch state 200 IUs, but Burns states 400 IUs. Extra 400-500 calories/day increased for mom. Growth spurts.


Insufficient milk supply causes

Poor diet, not pumping, long intervals between breastfeeding, use of supplementation between feedings, maternal stress/illnesses, sore nipples, estrogen (can inhibit milk supply). Usually not because they don’t have enough milk. It’s usually an external factor. Hypoplastic glandular disorder is rare and can cause decreased milk supply.


How to increase milk supply

Pump between/after feedings, increase water intake, good diet, avoid supplementation, increase skin-to-skin, switching breasts every 5 minutes to rouse infant, feed frequently


Watch alcohol intake

0.5 g/kg of weight. 8-ounce glass of wine, 2 beers, 2 oz of liquor in a day. Encourage to abstain but can have some. (wait 3-4 hours before breastfeeding after alcohol)


Caffeine intake

1-2 cups/day. Can cause irritability in baby or decrease iron


Vitamin supplement recommendation for vegetarian

B12 supplement for vegetarian.


Contraindications of breastfeeding

: HIV (in developed countries. In developing countries the risk is better than the contaminated water), active TB infection (2 weeks after resolution can begin BF), chemotherapy/radiation, galactosemia infant, illegal drug abusers. Most meds are ok, but methotrexate is not ok. Active herpes infection of the breast is contraindicated in BF. Genital/oral herpes is ok. Varicella: No. 5 days before delivery or 2 days after no BF. CMV: Yes, you can breastfeed (antibodies present in milk protect the baby). Hep B: Yes, because the baby is treated with immunoglobulin and immunization. Hep C: Yes, not shown to be transmitted via BF. Mainly HIV and active herpes on breast are contraindications regarding infections. Breast reduction surgery: Yes, can BF.


Cracked nipples

Begin feeding on the least sore side. This will allow the infant to satiate slightly and nursing will be less vigorous on the sore side. Return to alternating the beginning breast as soon as possible. Frequent, shorter feedings may lessen discomfort. Avoid excessive nipple drying. Lanolin or hind milk (secreted late in the feeding with a very high fat content) can be used to lubricate and soften nipples. Evaluate for infection (S. aureus has been associated with nipple fissures). All-purpose nipple ointment (APNO) can be used. Contains steroid (betamethasone), anti-fungal (miconazole powder), and antibiotic (mupirocin). Guide baby to breast, not breast to baby. Wash before and after nursing (soap and water). Nipple shields help a little bit (caution: they can decrease milk supply).



Usually unilateral. Red lump/streak, fever, chills, headache. Most common organism is Staph aureaus. Antibiotic dycloxicillin or augmentin x 10-14 days. Warm showers, moist heat, fluids, frequent BFing, pain medications. Do not need to stop breastfeeding. Can even BF on affected breast.



BF often, cold cabbage leaves, cold/ice packs, tea, heat 5-10 minutes before nursing, compresses, massage, expressing milk.



Can get from baby who has thrush. Both mother and baby should be treated.